• Safety culture
• Quality measurement
• Healthcare quality improvement

Patient safety culture (PSC) has become a hot topic within the healthcare safety community. PSC papers now appear by the hundreds; hospitals across the USA and Canada are mandated to survey culture; and numerous translations and validations in other countries have occurred. However, it is important to consider whether we are really gaining anything from all this surveying. PSC surveys have been compared with ‘describing the water to a drowning man’.1 That is, although PSC surveys are instrumental in helping organisations to identify opportunities to improve safety, they typically do not inform solutions. Plus, sometimes it does feel like we are drowning in PSC surveys.

PSC: Theory, Methods and Applications, edited by Patrick Waterson, examines the field of PSC and highlights the pervasive use of surveys and questionnaires in the current landscape. In contrast to other high-risk industries, healthcare researchers and practitioners seem to have embraced only a small subset of methods that could be used to measure PSC. PSC is commonly defined according to the following nuclear industry definition: “The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation's health and safety management”.2 Using this definition, which describes values, attitudes and perceptions, and competencies and patterns of behaviour, it appears the healthcare industry has only focused on measuring the first half of the definition (ie, values, attitudes and perceptions) but has neglected measurement of the second half (ie, competencies and patterns of behaviour).

PSC surveys and questionnaires have been invaluable for subjectively measuring and raising awareness about PSC. However, it seems we are missing an important opportunity to objectively measure competencies and patterns of behaviour that determine PSC in healthcare. Competencies and patterns of behaviour are not conducive to measurement by surveys and questionnaires. Instead, methods such as direct observations and ethnography better capture practitioners’ behaviour and communication patterns.

This book highlights that most, if not all, PSC studies in healthcare focus on a ‘culture as a causal attitude’ model (ie, an organisation's collective values, beliefs, assumptions and norms) and consequently, adopt surveys as the sole method to assess PSC. Most of this book focuses on surveys, though in the final chapter of the book Waterson rightfully points out that if we are to move the field of PSC forward, we will need to move beyond surveys.

The question of how healthcare institutions can improve their PSC and reduce harm to patients, which has been a major operational and research focus for the last decade, is examined in this book. Policy makers, researchers, managers, front line staff and medical device manufacturers alike, will gain an understanding of PSC, and learn about the available surveys and application of surveys from reading this book. It is recommended as a guide for researchers interested in studying the topic of PSC, and for managers and executives within healthcare organisations interested in applying surveys to measure practitioners’ values, attitudes and perceptions of PSC.

The international team of authors brings expertise from a range of backgrounds including medicine, quality improvement, patient safety and human factors. This array of perspectives facilitates a balanced exploration of the current status and future challenges of PSC, being reviewed clearly and compellingly. The authors highlight the importance of having processes, safety systems and regulations in place to ensure safety, emphasising it is humans who deliver safety, and therefore, to improve PSC effectively, safety interventions must be understood, accepted, habitually used and socially embedded within an organisation's culture.

This book is divided into three parts: In Part I, the authors begin by introducing the notion of ‘culture’. Culture is defined as a collective mental model, which is intertwined with the history of a group. Culture influences behaviour and individuals within the group interpret behaviours according to that culture. Thus, how a group internalises the standards and norms associated with that culture is important. The authors make this point salient by describing the difference between an obligated behaviour—the way we have to do things around here—versus an accepted PSC behaviour, the way we do things around here. After reviewing the background and theory of PSC, Part I concludes that, while it might be possible to impose policies and regulations in an attempt to ‘limit behaviours’, such limitations do not directly translate into culture change, in terms of underlying meanings, values and tacit assumptions.

Part II addresses the current barriers to improving safety culture in healthcare. Specifically, the authors discuss the tendency in healthcare to: (1) measure the easily measurable which can lead to a reductionist approach (eg, using a single factor ie, easily measured rather than using a multifaceted approach to measure the safety culture of an organisation); (2) apply a ‘tick-box approach’ to safety to prove to regulators the organisation is safe; (3) view poor quality (eg, hospital acquired infections) as an inevitable side effect of efforts to heal as opposed to striving to change attitudes about what constitute acceptable complications of treatment; and (4) train different clinical groups (eg, nurses, physicians) in siloed systems accountable to different professional bodies, hindering the development of shared norms and behaviours across clinical groups.

After examining these barriers, the authors go on to identify tools (mostly surveys and workshops) that have been adapted and implemented to measure culture in healthcare organisations. The remainder of Part II focuses on applications and misapplications of safety culture interventions (eg, safety walk-rounds, safety checklists), the importance of identifying safety performance indicators to improve the measurement and monitoring of safety, and the importance of using these indicators in proactive patient safety management (ie, focus on enhancing an organisation's ability to cope and be resilient to the work on a daily basis). In sum, Part II highlights the need for the field of PSC to move beyond an exclusive focus on the use of a very limited set of tools and expand its theoretical and methodological horizons.

Part III presents a number of PSC case studies conducted in different countries, including Scotland, Belgium, Switzerland, Germany, the Netherlands and the USA. Some case studies focus on identifying the key dimensions of PSC targeted for measurement and the associated instrument development. Other case studies focus on establishing empirical relationships between safety culture and specific metrics, such as incident reports, self-reports of worker and patient injuries, and self-reports of workers’ perceived safety compliance and safety participation behaviours. Still others examine the relationship between safety culture and specific patient safety practices—executive walk rounds, checklists, interdisciplinary rounds, medical team training, communication plans, mapping and improving transfer processes.

Although some of these initiatives have reported improvements in PSC, the authors note that caution should be exercised when interpreting the results from these studies. Moving forward, they urge researchers to pay more attention to: (1) reporting study sample characteristics and respondent profiles as survey results have been found to vary greatly across units and hospitals; (2) discussing the contextual influences that are likely to shape attitudes towards safety; and (3) assessing the longitudinal impact of interventions on changes in safety culture. Despite the voluminous data available as a result of the widespread use of PSC surveys, the current literature sheds little light on the nature and effectiveness of initiatives that healthcare institutions implement between their assessments of culture.

Part III also stresses the importance of looking beyond surveys, recommending the triangulation of quantitative and qualitative methods to attain a more accurate assessment of culture. It is often not possible to understand ‘why’ people think the way they do from survey results. As such, other techniques such as interviews, workshops and focus groups are recommended to help in placing survey responses in context.

The final chapters of the book examine more complex issues related to healthcare improvement initiatives, such as the culture of blame. It is well recognised that healthcare organisations must move away from a culture of blame, where staff are punished for their mistakes and consequently do not disclose near misses or errors out of fear. As a result, there are many missed opportunities for organisational learning and safety improvement. Healthcare organisations must move towards a ‘just culture’, in which people are encouraged to report errors so organisational learning can take place, and in turn, the quality and safety of care provided can be improved. Although this may sound simple, it is not always clear how to go about addressing the issue of safety culture, or how to translate theoretical notions into practical interventions and programmes. The authors recommend looking outside of healthcare to learn key lessons from other industries. In this way a better understanding of the sociotechnical context of work may be possible, allowing those in healthcare to work towards an improved systems approach to future PSC research and practice.

PSC: Theory, Methods and Application provides the novice with an easy-to-read introduction to PSC, while providing the experienced researcher or healthcare professional with a comprehensive, fully referenced resource that will help inform future PSC change efforts. The book provides readers with a summary of the definitions of PSC and safety climate; reviews the history of work on safety culture, identifies theoretical underpinnings, dimensions and measures of safety culture in healthcare, provides examples of PSC surveys; reviews the progress towards improving PSC using interventions (eg, safety walk-rounds, safety checklists); and details some of the prominent challenges facing PSC today.

Our one disappointment with this generally excellent book is that we struggled to find a ‘hook’ to hang onto, an overall approach that went beyond the typical PSC measurement strategies such as surveys and questionnaires, and covered strategies to measure competencies and patterns of behaviour as well as strategies to improve PSC. Having an overall guide or framework that includes a complement of safety culture methodologies that go beyond the initial probing would encourage future PSC researchers to branch out to methods such as ethnography for example, to assess competencies and patterns of behaviour.

With the dominant focus on surveying to date, it is worth considering whether we are looking too narrowly at PSC. First, we may be encouraging respondents to focus on concerns that are top-of-the-mind rather than perhaps more on fundamental or systemic issues. Over time, operations in healthcare can be expected to deviate from standard processes that were originally established to encourage safety. Efforts should be made to help healthcare organisations identify and manage unsafe practice deviations before they become normalised and pose risks to quality care and patient safety. Second, we may be examining safety risks typified by the analysis of incidents (ie, failures), and consequently, foregoing the benefits of also monitoring for positive deviance.3 While a few chapters in the book (particularly Chapters 9 and 18) discuss the importance of considering the power of positive deviance in facilitating the reproduction of these successes, the book primarily demonstrates that PSC studies tend to focus on surveys to measure culture. Therefore we have a long way to go to embed PSC into hospitals.

We offer the following suggestions in the use of this book:

1. Novices looking for an introduction to PSC will find Part I of the book most relevant. Experienced researchers interested in the methodological underpinnings of surveys as a measure of PSC will find Part II of the book most relevant. And, administrators and hospital staff charged with improving PSC will likely find Part III most relevant.

2. Although this book provides a good reference for surveys and questionnaires that can be used to study PSC, readers are encouraged to explore other methods (eg, ethnographic observations,4 ,5 simulation testing6) to better understand the applied impact of PSC interventions, so that research can contribute to the enhancement of fundamental understanding as well as the resolution of practical problems in the field of PSC.

The PSC of an organisation is an important part of a complex set of factors that contribute to providing safe, effective and high quality healthcare. PSC provides a necessary lens through which to view patient care, recognising that at the end of the day it is people who deliver safe care. Improving PSC requires understanding and accepting safety behaviours, and using them regularly. When that occurs, PSC becomes embodied not as the way we have to do things around here, but the way we do things around here.